June 25, 2012

New coverage guidelines under the Patient Protection and Affordable Care Act (PPACA) require health plans to cover an expanded list of women’s preventive care services with no cost-share (copayment, coinsurance or deductible) as long as services are received in the health plan’s network.

Impacted GroupsThe preventive care services provision applies to both fully insured and self-funded (ASO) plans that are non-grandfathered plans under the health reform law. While grandfathered plans are not required to implement these changes, some grandfathered plans have chosen to offer preventive care services at no cost-share. In addition, UnitedHealthcare Small Business plans (generally 2-99 employees) offer preventive care services at no cost-share regardless of grandfathered status.

Breast Feeding Counseling and SuppliesUnder the health reform law, lactation support and counseling as well as costs for renting breast-feeding equipment for each child’s birth are covered at no cost-share. UnitedHealthcare believes some members may prefer to purchase a breast pump rather than rent hospital-grade equipment. To offer a range of choices for our members, UnitedHealthcare will cover the purchase of a personal, double-electric breast pump at no cost to the member.

To rent or purchase breast pumps, members will be required to contact UnitedHealthcare or a network physician, hospital or durable medical equipment (DME) supplier. The physician, hospital or DME supplier will bill UnitedHealthcare directly for reimbursement. Members will not be able to purchase supplies, such as breast pumps, at retail and send the receipt for reimbursement.

If a member chooses to purchase or rent a breast pump from a non-network provider or DME supplier, then non-network preventive benefits would apply, if available. If no non-network preventive benefits are available, the breast pump would not be covered.

Contraceptive Methods and CounselingUnder the health reform law, health plans must cover FDA-approved contraceptive methods for women without cost-share. Some contraceptives, like oral contraceptives, are covered under the pharmacy benefit when the prescription is filled at a network pharmacy. The administration of contraceptives by a network physician in a medical setting (sterilization, services to place/remove/inject contraceptive methods) will be covered without deductible, copayment or coinsurance under the medical benefit.

The new requirement covers prescribed contraceptive methods, sterilization procedures, and patient education and counseling for all women with reproductive capacity.

UnitedHealthcare has determined that contraceptives with the same progestin are equivalent to each other. Therefore, each unique progestin contraceptive medication will be represented in Tier 1 without cost-share. A limited number of higher cost Tier 1 contraceptives will move to Tier 2 on July 1, 2012. Note that this will be for the Advantage Prescription Drug List (PDL) only.

Review the new list of Tier 1 contraceptives on the Advantage PDL and the Traditional PDL that also includes Pharmacy frequently asked questions (FAQs). The Advantage PDL Tier 1 contraceptives will post to myuhc.com on July 1.

Under the health reform law, religious institutions that offer insurance to their employees may be able to choose whether or not to cover contraception services.

Domestic Violence ScreeningToday and going forward, UnitedHealthcare covers age-appropriate preventive visits, including risk identification and guidance for risk reduction at no cost to the member. Domestic violence screening is included in the wellness examination codes provided under preventive care services benefits.

Gestational Diabetes Screening Gestational diabetes screening is required for coverage as a preventive service under the health reform law for pregnant women between 24 and 28 weeks of gestation and at the first prenatal visit for pregnant women identified to be at high risk for diabetes. UnitedHealthcare will cover gestational diabetes screening for all pregnant women, regardless of gestational week.

HPV DNA TestingToday and going forward, UnitedHealthcare provides coverage for cervical cancer screening. Under the expanded women’s preventive care services benefit, UnitedHealthcare will provide coverage for human papillomavirus (HPV) screening in all women age 30 and over to be paid without cost-share to the member. HPV is the most common cause of cervical cancer, so HPV testing can help prevent cervical cancer.

HIV Screening and Counseling and Sexually Transmitted Infections Counseling The health reform law requires health plans to cover counseling and screening for human immunodeficiency virus for all sexually active women, not just women at risk. The law also requires counseling for other sexually transmitted diseases.

The new coverage for well-woman visits under the health reform law will require multiple preventive visits in the same year for a woman to receive all recommended services, including prenatal care. Prenatal servicescovered with no cost-sharing include:

Routine prenatal obstetrical office visits

All lab services explicitly identified in the health reform law

Tobacco cessation counseling specific to pregnant women

Immunizations recommended by the Advisory Committee on Immunization Practices

Prenatal services not covered under the women’s preventive coverage include, but are not limited to radiology (i.e., obstetrical ultrasounds), delivery and high-risk prenatal services.